SBC Disclosure

Benefisio me Bwalabwal: Mili Kka Plano e Bwalúw me Óbwóssul Setbisio	Tempool Bwalabwal Yeey: [See Instructions]
_________________________:_______________________	Bwalabwalul: ___________ | Iital Plano: ______

W eeimwoscheel Benefisio me Bwalabwal (SBC) dokumento yéél ebwe alisi yóómw affil mil ghatsch plano. SBC ebwe abwaari ngelugh meeta yeel me plano aubwe schuu reel óbwóssul mili kka e bwalabwal na setbisio. WERI: Infotmasion reel góóstol plano (iital nge premium) ikka eppwaal isisiwow. Milleel nge weeimwoscheel schagh. Ngare u mweschel mas infotmasion reel mili kka e bwalabwal, ngare copial alongal bwalabwal, [insert contact information]. Seletil kkapas kka allowed amount, balance billing, coinsurance, copayment, deductible, provider, me akkááw kkapas, amwéri réél Glossary. Emmwel ubwe weri Glossary reel [www.insert.com] ngare faingi 1-800-[insert] bwe ubwe tingór yóómw copy.

Mil Impotante Aiyegh	Appalúwal	Búlúúl Lifilifil Yeey
Meta mas na deductible?	$	Inaamwo meet, e nisisita ubwe óbwóssuw ló alongal góóstol providers tori deductibles, ngare plano ebwe mwóghut le óbwóss. [For family coverage, see instructions for additional applicable language.]
Eyoor mas setbisio kka e bwalabwal ilummwal yóómw deductible?	Aawer. [Insert: major categories]	Plano yeel nge e bwalúw akkááw séfay me setbisio inamo igha úseel ghúúla yóómw deductible. Nge emmwel bwe copayment me coinsurance ebwe apply. [For non-grandfathered plans, insert: “Ngare example, plano yeel e bwalúw akkááw preventive services sin cost sharing nge usel schuungi yóómw deductible. Piipiiy listal mili kka e bwalabwal na preventive services reel https://www.healthcare.gov/coverage/preventive-care-benefits/.”]
Eyoor mas deductibles reel akkááw setbisio?	Aawer. $	Ubwe óbwóssuw ló alongal góóstol setbisio kkei tori yóómw deductible bwe ila nge plano ebwe mmwel le mwóghut.
Meeta mas óbwóssul out-of-pocket limit reel plano yeel?	$	Out-of-pocket limit nge ila tómoghol mile ubwe óbwóss lóll yeew ráágh [For family coverage, see instructions for additional applicable language.]
Meeta kka ese bwalabwal lóll out-of-pocket limit?	[Insert: major exceptions]	Óbwóss kkei nge ese páápá ngare out-of-pocket limit.
Emmwel ubwe amééw ngare e tetiiw óbwóssul network provider?	Aawer. Piipiiy [www.insert.com] ngare faingi 1-800-[insert] listal network providers.	Eyoor network provider reel plano yeel. Ubwe óbwóss ghitighit ngare u yááyá provider me lóll planun network. Ubwe óbwóss tchow ngare u yááyá out-of-network provider, me emmwel ubwe resibiiy billing me reel provider reel diferensial góóstol me meeta plano ebwe óbwóssuw (balance billing). Amweri bwe yóómw network provider emmwel ebwe yááyá out-of-network provider reel akkááw setbisio (ngare lab work). Ghommwal ailééw yóómw provider ngare meeta na setbisio eyoor.
U nisisitai referral ngare ubwe weri specialist?	Aawer.	Plano yeel ebwe óbwóssuw eghus ngare alongal yóómw góósto reel specialist reel mili kka e bwalubwal na setbisio nge eyoor yóómw referral bwe ubwe weri specialist.

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